The wider availability of injectables is an opportunity to reach more people with more information through a variety of media. With a few exceptions, most programs have limited experience communicating about injectables. Typically, programs have gone no further than to produce informational print materials for clients and providers—for example, posters, brochures, or flip-charts—that describe injectables along with the other contraceptive methods. As access to injectables increases, so does the need for complete and readily accessible information about injectables.

Effective communication efforts start with research. Needs assessments or situation analyses identify audiences, their interests and concerns, and how they can be reached. A particular issue with injectables is women's responses to menstrual disruption—responses that differ from country to country and even within countries (see Bleeding Changes of Chapter 4).

Research methods include surveys, interviews, focus-group discussions, observation of providers, and evaluation of communication channels and facilities. For example, Demographic and Health Surveys and other national surveys can help programs identify audiences. Such surveys may report a high percentage of women intending to use family planning, and many of these women may say that they plan to use injectables. In Kenya, for example, 58% of currently married women not using contraception said that they intend to use family planning at some time, and 44% said that they intend to use family planning in the next year. Among women intending to use family planning at some time, 41% said they planned to use injectables (156).

Well-planned communication programs can help these women carry out their intentions. Messages may need to address public attitudes towards family planning in general, public knowledge of injectables, and the history of controversy about DMPA.

Public attitudes toward family planning. What characteristics of injectables can communication programs emphasize? The convenience of injectables is one of their most attractive characteristics. Surveys in places as different as Egypt and the Philippines find that "easy to use" is a major asset for any contraceptive (140, 161). Research on injectables confirms this finding. For example, in focus-group discussions conducted by the Social Marketing for Change (SOMARC) project in Nepal, women suggested the brand-name for DMPA of "Easy 3-month injection" (307).

The reversibility of injectables also can be an appealing feature. In Nepal surveys find that people associate contraception with sterilization, and many are unaware of the possibility of birth spacing. In the 1991 Fertility, Family Planning and Health Survey, 14% of women said that they would like to space children, but only 1% were using contraception. Thus the Contraceptive Retail Sales project, which sells DMPA, plans to emphasize reversibility in its social marketing promotion of the injectable (117, 307).

In Zimbabwe programs have informed the public about injectables while encouraging men to share responsibility for family planning. In the mid-1980s research found that men often made the decisions about family planning and family size and that men wanted more information about family planning. Therefore, in programs conducted from 1987 to 1994 by the Zimbabwe National Family Planning Council with assistance from Johns Hopkins Population Communication Services, weekly radio dramas addressed men; posters and newspaper and magazine articles informed the public about long-acting methods; costumed performers portraying injectables and other contraceptives clowned on the football field during a tournament; and providers offered family planning counseling at community events. Surveys before and after a campaign in 1993-94 found significant increases in the percentage of men who approved of injectables, from 55% to 67%, and in the percentage of women who said their partners approve of injectables, from 46% to 60% (160, 174).

Of course, some women use injectables because they do not want their husbands to know that they are using contraception. Communication programs generally do not publicly emphasize this attribute of injectables. Rather, they encourage partners to talk and reach agreement about family planning. Women use injectables longer when they have the support of their husbands (267). Using injectables secretly is best discussed informally by providers in one-to-one counseling. While encouraging couples to discuss family planning, programs should take care not to alienate women who cannot talk with their partners about family planning.

Public knowledge. The broadcast media, widespread distribution of brochures and posters, and promotion ofprofessional providers have helped to increase knowledge and use of injectables. Most of these programs cover injectables along with other available methods. In Tanzania, for example, a multimedia campaign conducted from 1991 to 1994 by the Ministry of Health produced posters, radio spots, and method-specific leaflets describing injectables and other long-term methods. A national introduction and introductions in several regions attracted press and public attention. After the campaign a survey in three regions found that the percentage of men and women ages 15 to 44 who mentioned injectables without prompting had risen from 18% to 49%, and use of injectables had risen from 1% to 3% (142). Overall, in 1991-92, 0.4% of married women in Tanzania used injectables (224). In Pakistan an estimated 20 million people saw the 13-part television drama, Nijaat (Deliverance), one episode of which showed a couple considering their contraceptive options and choosing an injectable (119, 147). In Indonesia the Blue Circle campaign promotes the family planning services of private doctors and midwives who provide injectables and other methods (295). The campaign distributed a leaflet on injectables for clients that asks, "Mothers, do you know enough about the injectable contraceptives?"

A full-fledged communication program may not always be necessary. The McCormick Family Planning Program in Thailand depended mainly on word of mouth. In its first four years the program attracted 60,000 clients, two-thirds of whom chose DMPA. Women in the program area had a strong desire for family planning and trusted the McCormick Christian Hospital, which ran the program (20).

Communication programs also can help to make sure injections are safe. Programs can portray providers using safe injection technique and encourage women to insist that their injections are safe.

The history of controversy about DMPA. Communication programs need to address providers and the public, who may ask how a drug that was once suspected of being dangerous can now be thought safe. Programs can point out that the fears were based on studies in animals and that more reliable epidemiological studies in women have now been completed.

Information about the latest research on DMPA can be presented in special seminars, as has been done in Ecuador, Peru, and the Philippines, to educate policymakers and providers. In Ecuador and Peru injectables are well known, but many providers consider them dangerous. Seminars in both countries have paved the way for limited introduction or expansion of services (51, 84, 255). In the Philippines the Department of Health produced an information kit for providers that stresses the extensive research underlying US FDA approval of DMPA. The kit also cites support for family planning by the Philippines president and health secretary, the popularity of DMPA in the Philippines, and the country's ability to produce DMPA (248). New service guidelines emphasize the importance of client education (125). The social marketing program in the Philippines placed an advertisement in the Manila Bulletin entitled "Facts about Depo-Provera." It cites studies of DMPA in the Philippines, describes use of the method in developed countries and approval in the US, emphasizes that DMPA is reversible, and refutes the rumor that it is an abortifacient (53). Also, the program has trained family planning providers to be interviewed on television and radio and to counter misinformation and false rumors about DMPA (18).

In India, however, such efforts have failed to reassure some groups opposed to DMPA. The Upjohn Company worked with the Indian Council of Medical Research (ICMR), which has endorsed DMPA. Upjohn also invited policymakers from Thailand to discussions with Indian scientists and policy~makers (91). Some women's groups are unconvinced that DMPA is safe, however, and their challenges have delayed the introduction of DMPA into the national family planning program.

Working with groups opposed to DMPA, government agencies can address some of their concerns. US FDA officials, for example, have met with representatives of the National Women's Health Network to discuss establishing a national registry of DMPA users that would track side effects (244).